Less than 2% of patients received referrals in Canadian study

Action Points

Note that this observational study using data from inpatient admissions suggests that those with advanced chronic obstructive pulmonary disease rarely received palliative care services.

Even among those who received invasive ventilation, fewer than 10% had a palliative care contact.

Only a very small minority of patients with end-stage chronic obstructive pulmonary disease (COPD) were referred for palliative care even though these patients have a short life expectancy and a large symptom burden, according to Canadian researchers.

While the utilization of palliative care services increased 4.5-fold from 2006 to 2012 among hospitalized COPD patients on home oxygen included in the study, the overall rate of referral was still just 1.7% during this time, reported Barret Rush, MD, of the University of British Columbia in Vancouver, and colleagues.

The rates were even lower among blacks and Hispanics, patients living in poverty, and those living in rural areas, they wrote in CHEST.

Even though palliative care is endorsed for COPD patients with end-stage disease by the majority of respiratory societies, the uptake of this service has lagged far behind that seen in patients with metastatic cancer, the authors noted.

"Like patients with end-stage cancers, this is a population with huge symptom burden and a short life expectancy," Rush told MedPage Today. "The opportunity to improve quality of life in these patients is enormous, but palliative care is an underrecognized and underutilized therapy in patients with COPD."

Rush noted that patients admitted to hospitals with a COPD exacerbation have a median survival of about 2 years, and half of these patients will be readmitted within 6 months. End-stage patients on home oxygen therapy that required mechanical ventilation during hospitalization for an exacerbation were found to have a 1-year mortality of 45% in one recent study.

The current nationwide analysis included patients with COPD on home oxygen therapy who were admitted to hospitals for COPD exacerbations from 2006 to 2012. The researchers analyzed data from the Nationwide Inpatient Sample (NIS).

During this time frame, there were more than 55 million hospitalizations for COPD recorded in the database, with 181,689 patients on home oxygen admitted to hospitals. Just 3,145 of these patients (1.7%) had a palliative care contact.

All minority groups had less access to palliative care services than whites: OR 0.83 for black race (95% CI 0.71-0.97, P=0.02) and OR 0.68 for Hispanic race (95% CI 0.52-0.88, P<0.01).

Compared with hospitals in the Northeastern U.S., all other regions of the country had higher access to palliative care, and treatment in large hospitals (OR 1.22, 95% CI 1.10- 1.36, P<0.01) as well as medium-sized hospitals (OR 1.19, 95% CI 1.05-1.34, P<0.01) was associated with more access to palliative care referral.

Patients treated at urban teaching hospitals were more than twice as likely to be referred for palliative care as those treated at rural hospitals (OR 2.19, 95% CI 1.93-2.48; P<0.01).

Rush noted that the increase in palliative care consultation in these larger hospitals probably explains the increase in access to these services among patients with end-stage COPD.

He noted that while the use of hospital discharge data in this study may limit the generalizability of the findings, it is clear that palliative care uptake in COPD is very low nationwide.

"I do expect that the use of palliative care will increase for patients with diseases like COPD and heart failure as awareness grows," he said.

Rush and co-authors disclosed no relevant relationships with industry.

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